Presentation
Using Metric-Based Clinical Simulation to Evaluate Procedural Tasks and Clinical Decisions During Ostomy Appliance Change Procedures Performed by Nurses with Different Nursing Credentials
DescriptionHuman factors and usability evaluations are recognized by the Food and Drug Administration (FDA) as important for medical device safety and effectiveness and are widely used to improve health care quality and patient safety. Assessment of human factors in medical procedures includes user participation in simulated clinical environments, and simulation pedagogy is widely used for teaching and assessing nursing skills. Simulation allows users to gain hands-on experience and allows researchers to examine the user interaction with medical devices while performing tasks in realistic yet safe environments. While human factors and simulation techniques have been used to assess nursing care, they have not been applied to assess the psychomotor and cognitive tasks essential for delivery of high-quality ostomy nursing care.
This study explores factors associated with ostomy appliances that are used by individuals living with a stoma after ostomy surgery. Over 100,000 ostomy surgeries are performed annually in the United States and involve rerouting excreta from internal organs through an abdominal stoma and into an ostomy appliance. Ostomy appliances require users to perform critical self-care tasks that include frequent pouch changes and skin care. After ostomy surgery, patients rely on instructions provided by nurses to guide their at-home ostomy care, which influences their development of self-care skills. Unfortunately, peristomal skin complications (PSCs) are a persistent challenge affecting approximately one-third of patients within 90 days of ostomy surgery. PSCs are highly influenced by the fit and adhesion of the appliance and are less common in patients who receive ostomy care education from ostomy nurse specialists. However, there is a shortage of certified ostomy care nurses (COCN) and a need to extend ostomy nursing care education to non-specialty nurses.
Clinical competencies (skills and knowledge) in ostomy nursing care and their influence on safety (peristomal skin health) and outcomes (patient recovery and health related quality of life) following ostomy surgery are not well understood within a human factors context. Competence in performing ostomy skin care is important because it has been shown that experts and novices perform work differently. According to Benner’s theory of clinical competence in nursing practice, expertise develops through proper education and experience over time, ultimately enabling holistic assessment to guide clinical decisions. Nurses without ostomy nursing care credentials are often responsible for educating and training patients in self-management of care, and these non-specialty nurses report being uncomfortable managing ostomy problems. Different care environments, such as acute-care or home-health settings, can also influence ostomy nursing care delivery. For these reasons, simulation of ostomy nursing care could enhance the understanding of current clinical practices with ostomy appliances and support training and skill development of the nursing workforce.
The purpose of this study was to explore both clinical practice and decisions made during ostomy appliance change procedures performed by nurses with different nursing credentials using a validated metric-based clinical simulation procedure. This was accomplished by: 1) documenting discrete tasks and task duration related to product selection, skin care, baseplate sizing and adhesion, and infection control strategies from video recordings of four nurse groups completing ostomy simulation trials; 2) assessing perceived usability through the system usability scale (SUS) for each participant; and 3) describing clinical decision making in ostomy nursing care practice using qualitative analysis of debriefing interviews.
This study was conducted within a School of Nursing located at a healthcare institution in the southeastern United States. The standard testing simulation environment included a fully equipped acute-care patient room with an enhanced nursing mannequin simulator, which was capable of ejecting simulated stoma effluent with physiological fluid properties. The mannequin peristomal skin was covered with a silicone sheet to simulate baseplate adhesion to human skin.
Based on the Benner’s stages of clinical competence, nurses with different nursing credentials were recruited as study participants: certified ostomy care nurse specialists (COCN+ group), registered nurses working in acute care (RN group), home-health nurses (HH group) and senior prelicensure baccalaureate student nurses (SN group). Each participant was introduced to the study, reviewed and signed the informed consent, and was given a pre-briefing describing the simulation environment. Each participant was instructed to complete the ostomy appliance change procedure and engage with mannequin “Anne” as they would in a clinical setting. Each participant completed three trials, and then completed the SUS survey and simulation debriefing session with the facilitator.
A validated structured review instrument was used to extract information from video recordings related to: i) clinical practice, more specifically, discrete tasks and the order they were performed, ii) task duration such as overall procedure time, stoma and peristomal skin care time, and reapplying appliance time, and iii) supplies used. Discrete tasks performed, task duration, and supplies used were then grouped in the following categories: product selection, stoma and peristomal skin care, baseplate sizing and adhesion, infection control strategies, final baseplate opening size, and time duration. The baseplate of the changed ostomy appliance, collected from the mannequin abdomen upon completion of each trial, was imaged and analyzed for the area and roundness of the molded or cut opening size using image analysis software. Recorded participant comments were transcribed verbatim using NVivo Transcription software and analyzed using content analysis.
Statistical models were used to evaluate several outcome variables, including: product selection, stoma and peristomal skin care, baseplate sizing and adhesion, and infection control tasks considered binomial categorical variable (e.g., “performed/did not perform” or “used/did not use”) and task duration, final baseplate opening size, and SUS score considered as continuous response variables. Statistical tests were performed to determine if the measured responses differed among the nurse groups (COCN+, RN, HH, and SN) and the trials (1, 2, and 3). Data analysis for the HH group is ongoing.
There were (n=26) participants in the study, including the COCN+ group (n=6), RN group (n=8), SN group (n=10) and HH group (n=2, with data collection ongoing). To date, approximately 518 min of video recordings and 72 baseplate images have been analyzed. Differences between nurse groups include: i) COCN+ group spent significantly longer time on skin care when compared to SN group and RN groups; ii) COCN+ group spent significantly longer time reapplying the appliance when compared to SN and RN groups; iii) the final baseplate opening size area was significantly smaller for COCN+ group when compared to SN group; and iv) visual differences and variations were observed in final baseplate opening smoothness.
Overall, the results of this study identified variations in clinical decision-making and clinical practice within ostomy care and thus highlights education topics to be emphasized for non-specialty nurses such as product selection and use, peristomal cleaning techniques, baseplate sizing strategies and infection prevention strategies. Significant differences between groups were observed for all four task categories for ostomy nursing care (product selection n=14, skin care n=8, baseplate sizing and adhesion n=4, and infection control n=8). There were differences in perceived usability of ostomy appliance change procedure, with similar SUS scores between COCN+ and RN groups indicating above average perceived usability and below average perceived usability for SN group. Participants from all nurse groups made comments related to assessment, intervention, and education that reflected differences in decision making and clinical practice that aligned with different stages of competence in clinical ostomy nursing care practice. These study results aligned with Benner's framework of clinical competence in nursing practice.
This study explores factors associated with ostomy appliances that are used by individuals living with a stoma after ostomy surgery. Over 100,000 ostomy surgeries are performed annually in the United States and involve rerouting excreta from internal organs through an abdominal stoma and into an ostomy appliance. Ostomy appliances require users to perform critical self-care tasks that include frequent pouch changes and skin care. After ostomy surgery, patients rely on instructions provided by nurses to guide their at-home ostomy care, which influences their development of self-care skills. Unfortunately, peristomal skin complications (PSCs) are a persistent challenge affecting approximately one-third of patients within 90 days of ostomy surgery. PSCs are highly influenced by the fit and adhesion of the appliance and are less common in patients who receive ostomy care education from ostomy nurse specialists. However, there is a shortage of certified ostomy care nurses (COCN) and a need to extend ostomy nursing care education to non-specialty nurses.
Clinical competencies (skills and knowledge) in ostomy nursing care and their influence on safety (peristomal skin health) and outcomes (patient recovery and health related quality of life) following ostomy surgery are not well understood within a human factors context. Competence in performing ostomy skin care is important because it has been shown that experts and novices perform work differently. According to Benner’s theory of clinical competence in nursing practice, expertise develops through proper education and experience over time, ultimately enabling holistic assessment to guide clinical decisions. Nurses without ostomy nursing care credentials are often responsible for educating and training patients in self-management of care, and these non-specialty nurses report being uncomfortable managing ostomy problems. Different care environments, such as acute-care or home-health settings, can also influence ostomy nursing care delivery. For these reasons, simulation of ostomy nursing care could enhance the understanding of current clinical practices with ostomy appliances and support training and skill development of the nursing workforce.
The purpose of this study was to explore both clinical practice and decisions made during ostomy appliance change procedures performed by nurses with different nursing credentials using a validated metric-based clinical simulation procedure. This was accomplished by: 1) documenting discrete tasks and task duration related to product selection, skin care, baseplate sizing and adhesion, and infection control strategies from video recordings of four nurse groups completing ostomy simulation trials; 2) assessing perceived usability through the system usability scale (SUS) for each participant; and 3) describing clinical decision making in ostomy nursing care practice using qualitative analysis of debriefing interviews.
This study was conducted within a School of Nursing located at a healthcare institution in the southeastern United States. The standard testing simulation environment included a fully equipped acute-care patient room with an enhanced nursing mannequin simulator, which was capable of ejecting simulated stoma effluent with physiological fluid properties. The mannequin peristomal skin was covered with a silicone sheet to simulate baseplate adhesion to human skin.
Based on the Benner’s stages of clinical competence, nurses with different nursing credentials were recruited as study participants: certified ostomy care nurse specialists (COCN+ group), registered nurses working in acute care (RN group), home-health nurses (HH group) and senior prelicensure baccalaureate student nurses (SN group). Each participant was introduced to the study, reviewed and signed the informed consent, and was given a pre-briefing describing the simulation environment. Each participant was instructed to complete the ostomy appliance change procedure and engage with mannequin “Anne” as they would in a clinical setting. Each participant completed three trials, and then completed the SUS survey and simulation debriefing session with the facilitator.
A validated structured review instrument was used to extract information from video recordings related to: i) clinical practice, more specifically, discrete tasks and the order they were performed, ii) task duration such as overall procedure time, stoma and peristomal skin care time, and reapplying appliance time, and iii) supplies used. Discrete tasks performed, task duration, and supplies used were then grouped in the following categories: product selection, stoma and peristomal skin care, baseplate sizing and adhesion, infection control strategies, final baseplate opening size, and time duration. The baseplate of the changed ostomy appliance, collected from the mannequin abdomen upon completion of each trial, was imaged and analyzed for the area and roundness of the molded or cut opening size using image analysis software. Recorded participant comments were transcribed verbatim using NVivo Transcription software and analyzed using content analysis.
Statistical models were used to evaluate several outcome variables, including: product selection, stoma and peristomal skin care, baseplate sizing and adhesion, and infection control tasks considered binomial categorical variable (e.g., “performed/did not perform” or “used/did not use”) and task duration, final baseplate opening size, and SUS score considered as continuous response variables. Statistical tests were performed to determine if the measured responses differed among the nurse groups (COCN+, RN, HH, and SN) and the trials (1, 2, and 3). Data analysis for the HH group is ongoing.
There were (n=26) participants in the study, including the COCN+ group (n=6), RN group (n=8), SN group (n=10) and HH group (n=2, with data collection ongoing). To date, approximately 518 min of video recordings and 72 baseplate images have been analyzed. Differences between nurse groups include: i) COCN+ group spent significantly longer time on skin care when compared to SN group and RN groups; ii) COCN+ group spent significantly longer time reapplying the appliance when compared to SN and RN groups; iii) the final baseplate opening size area was significantly smaller for COCN+ group when compared to SN group; and iv) visual differences and variations were observed in final baseplate opening smoothness.
Overall, the results of this study identified variations in clinical decision-making and clinical practice within ostomy care and thus highlights education topics to be emphasized for non-specialty nurses such as product selection and use, peristomal cleaning techniques, baseplate sizing strategies and infection prevention strategies. Significant differences between groups were observed for all four task categories for ostomy nursing care (product selection n=14, skin care n=8, baseplate sizing and adhesion n=4, and infection control n=8). There were differences in perceived usability of ostomy appliance change procedure, with similar SUS scores between COCN+ and RN groups indicating above average perceived usability and below average perceived usability for SN group. Participants from all nurse groups made comments related to assessment, intervention, and education that reflected differences in decision making and clinical practice that aligned with different stages of competence in clinical ostomy nursing care practice. These study results aligned with Benner's framework of clinical competence in nursing practice.
Event Type
Oral Presentations
TimeTuesday, March 2411:37am - 12:00pm EDT
LocationMorgan
Simulation and Education